Service Users at the heart of inter-professional workingby Vikki Barry

1. The patients association is an example of this and is worth further reading it has real examples in practice from the patients perspective.

2. Patient confidentiality is very important and as professionals we must abide by certain laws to keep patients information safe. However, this does make IPW difficult as we sometimes don't always know which information we should or should not share. Although there are guidelines to follow, there are still some gray areas, especially when it comes to safeguarding. knowing we can share information when someone is at risk is not enough. What if we suspect risk? Is that enough?

3. I believe that when inter-professional working goes wrong patients start to suffer, Especially the older generations. after working on a elderly ward I found that many patients were medically fit for discharge, just had no where to go. I think sometimes due to being busy chasing up the referrals to social workers don't get done as fast as they should do. This is just from my experience.

4. The NHS Plan, 2000: White Paper - Looked at the development of partnerships and co-operation at all levels of care to ensure a patient-centred service. This making sure patients are involved in their own care, linking with the health and social care act 2003.

5. If interprofessional working is used then it is likely a patient will have a good experience and feel valued, as well as staff feeling motivated because everyone is aware of the full situation occurring with a patient. Better decision making is a likely benefit of goof interprofessional working.

5.1. Interprofessional working is only successful when effective communication is used, as sharing of the appropriate information is essential when aiming to provide the best standards of care. While on placement I have witnessed positive communication sharing, where the doctors, nurses and physiotherapist all worked as a team to overcome the difficulty a patient had regarding the pain the person felt when walking. However I have also observed ineffective communication skills, where little or no information was being shared, this can often prelong the period of recovery for a paitnet, in some cases may be damaging to the paitent health if

6. When it is decided that a patient is coming to the end of their life and needs palliative care there are discussions that go on between the patient, the professionals working with them and their family in order to discuss the patients needs and wishes at this time. This allows the patient to make their own decisions at this time so that they can pass away comfortable and with dignity. Palliative care also supports their family at this time to ensure that they are coping and that the patient is not worried about their family. In order to make this palliative care effective services must use inter-profesional working to ensure that the best possible plan is set out and that everyone involved with the patient know what their needs and wishes are.

7. i have found that sometimes when nurses are talking to patients they are asking empathetic and caring questions but they are normally doing something else at the time (eg. setting up for a procedure or giving meds) therefore when the patient responds, their views aren't being listened to effectively. As a student i am able to pick up on this and inform the nurse at the time but i worry that what happens when this is not able to happen. These experiences have reconfirmed that it is essential to listen to patients regardless of how busy we are as professionals

8. In some cases the patient/service user are not the expert as there is cases where the patient does not have capacity which can result in neglect. On the other hand some patients are experts and they know their condition and treatments very well.

9. The nursing and midwifery council Code (2015) section 5 states that professionals should share necessary information with other healthcare professionals and agencies only when the interests of patient safety and public protection override the need for confidentiality. This therefore means that professionals are using their inter-professional working to put the patient at the center of their care and make sure that they share information with all the services they need in order to give that patient the best possible care.

10. This piece of legislation sets for professionals to collaborate along with service users for better integrated care

11. I have recently visited a lady who is under palliative care and this women can come across rude and be very particular with the nurses who attend her leg dressings. After this recent visit she explained she had seen physio's, OT's, pharmacists and nurses. She went on to say that she had been waiting awhile to see the district nurses and then she gets 3 visits a week. She told ,myself and the nurse she wasn't happy with the lack of communication and was worried about how she would be cared for when she deteriorated and if near the end stages of her life, if she is not able to say she is not happy with her care who will be? In this case this lady has been seen several times but appears people have not communicated about her case and if they had of done; would they have built a better relationship with the patient and been able to ease her worries?

12. I would like to think that everyone wants to be involved in their care. I just think that some people want more involvement then others. The patient would have to have some form of involvement, as we are unable to do anything without providing the patient with all information and gaining consent.

13. The Nursing and Midwifery Council is a very important policy that we should follow. It ensures professional bodies keep up to date with relevant training,conducts, performances, skills and knowledge to uphold our professional body. It is important that the highest quality of care is given to all service users, which is supported by the 6c's nursing values that underpin compassionate care in practice. The values are care, compassion, competence, communication, courage and commitment. Care is about delivering the best care for the individual to improve their health and quality of life. Compassion is about how health professionals care for patients by giving empathy, respect and dignity, which should be upheld at all times. Competence is about making sure all caring roles have the ability to understand a patients health by having the knowledge to understand. This is also about not doing anything that is out of your limits. Communication is about listening and communicating with staff and patients effectively to meet their individual needs. Courage is about having the courage to speak put about any concerns that have been observed E.g safeguarding. The last value is commitment, which is about being committed to the role and build on it to improve patients care and experiences.

14. Working together to Safeguard Children 2006 - all professionals must understand the roles of others and all have a shared responsibility as a inter-professional team to protect and safeguard children.

15. We are guided by our professional bodies and use our individual professional codes of conduct and the HCPC to help with our decision making, and professional conduct. Although we all share policy and legislation, such as Working together to safeguard children (2006) meaning that we can all work on a similar ground to protect and safeguard patients as a whole, interprofesionally.

16. this helps guide us and underpins our professional judgement.

17. Legislation

17.1. 5 Years forward (2014)

17.2. Working for patients 1989

17.3. Health and social care act 2003

17.3.1. This sets for patients to be involved in their own care, which is inportant as they have the right to know what is happening and who is involved in their care.

18. Policy and guidance

18.1. Policy and guidance set clear standards for all professionals to follow this links in to providing effective IPW and putting the service user at the heart of IPW by ensuring all professionals meet the same standard of care.

19. Information Governance

19.1. Ensuring information is confidential

19.1.1. We need to ensure that the way we share information is secure too - the networks we use to transfer data need to be secure. This is so that information is only given to the right personnel. This may include using encrypted systems to transfer data. Sometimes using the same online record keeping system, e.g. system one can make accessing information safe and easy.

19.2. The danger of better communication is obviously security. Better training on information governance has really helped bridge that gap. Even from year one in training it is delivered to us.

19.2.1. Not leaving confidential patients paperwork on the side which would allow anyone to pick them up, they should ideally be stored in locked cupboards and put away everytime. this would ensure confidentiality as well as respect and dignity for patients.

19.3. We need to make sure that all of our confidential paperwork is not left out in the open for anyone to pick up. But we need to also make sure that we know when to get rid on confidential waste and make sure that it is disposed of correctly. Along with this confidential documents need to be transferred over on to a secure site, to provide the patients with a sense of security with their information.

20. Inter-professional and inter-agency collaboration

20.1. this is key to ensuring resources are used efficiently, such as time, money, staff.

20.2. Both inter-professional and inter-agency working are essential for best patient care. Each professional is an expert in their field meaning the patient can benefit from a package of holistic, expert care by a number of professionals.

20.3. inter agency collaboration is crucial to ensure that patients not only get good quality care but also get it in a timely manner as prolonging the process can lead to stress and anxiety.

20.4. We need to maintain our professional identities, we all have specific roles. We are the experts in our roles but in order to provide the best patient centred care we need to share the knowledge we have and communicate effectively within our inter professional team.

21. Source of our information, Experts in their own care

21.1. $£$ MONEY £$£$- How often do we hear that the money pot for the NHS is going. You only have to work on a ward to see that. Good IPW saves money. Good Integrated care will save money. Like the story about Sam we saw in the video. Community and acute communication needs to be excellent.

21.1.1. This is true, especially with patients who have long term chronic illnesses. My experience with diabetic patients is that they tend to know when their insulin is needed and if they think their blood sugar level is low. They are the only ones who would know this and therefore, it would be irresponsible of us as healthcare providers to not have them at the center of their care.

21.2. in day to day care in both acute and community settings i think that the patients input and needs are valued and appreciated but in emergency situations when rapid action is needed, ive found that doctors and nurses respond in a manner they think to be the best action which may not be inline with the patients wishes.

21.3. In practice patients/service users need to be viewed as the experts, is this always the case in your experience?

21.3.1. I believe patients with capacity DO know what is best for them. We should never force things upon our patients. Maybe from a professional perspective it is not the best decision, but for them it is their decision and what they want. However what we can do is speak to them about what we believe is best for them and WHY. Explaining why shows our professional input. We can talk to them about the benefits from listening to our advice, and the dangers from not. From here they can then make their decision, At the end of the day it is their lives and they should be able to make their own decisions in it if they have capacity, and we should respect this.

21.3.2. In my experience, the patient has often been the expert, but also the family members. When in a hospital setting and a patient is admitted to a ward, that is often the first time that the staff will have met that individual. The patient knows what is the norm for them but when there are communication barriers, the family can be a good source to say when something isn't quite right. On the other hand, healthcare professionals often know what's best for specific things. For example, after surgery, a patient may doubt their ability and say they can't do certain things. Healthcare professionals know what's best to do in certain situations (e.g mobilising) and that's when encouragement is needed.

21.3.3. I'm completely 50/50 with this statement. I feel sometimes when a patient is an "expert" in the chronic illness they have, it can some ways become an obsession for them. For example, on placement I was looking after a patient with COPD and I noticed they became fixed on maintaining their oxygen saturations and if they had dropped it would make them anxious and worried about being able to go home which ultimately is not doing them any good health wise. But on the other hand it helps in other situations such as on my community placement, where I'm seeing patients with leg dressings, they tend to tell you what dressings to put where as that's what they know what's best for them.

21.4. In most cases I believe that service users are the expert in knowing what is the best form of care and treatment they receive. By working as a multi- professional team and sharing our expertise and knowledge to the service user can they then decide upon the best care pathway to follow. It is then our job to keep up to date with all current research and evidence that we can then refer to when justifying our own recommendations.

22. Service users needs and wishes at the centre

22.1. Often we can be too busy to think about what their needs and wishes are. the gentlemen story near the end really made me rededicate myself in taking the time to speak to them and asking what they want.

22.2. Making sure person centred care is given and people don't just follow routines and make sure to treat individuals as individuals,

22.3. Sometimes when on shift there is not enough time as we would like to have for our patients and this is a re-occurring issue throughout health and social care. However I believe it is key to have our patients well-being at the centre of work, so no matter how busy or how little time, making sure their wishes and needs are met is of great significance. They are not just patients, they are real people.

22.4. services users should be at the the heart and centre of everything we do which is highlighted in the principles of the NHS constitution and all of our professional codes. An important aspect of providing high quality evidence based care is taking into account the serivies users wants, needs and preferences. This can present eithical dilemas for health professionals when service users decline treatment that sometimes may result in harm to their health and in extreme cases may result in their death. However, as health professionals if the person in question has capacity we are obliged to respect service users right to decline treatment

22.5. The point about not just being patients..they are real people, is fundamental in the care given. I think sometimes professionals forget this and I have seen the attitude that everything is a nuisance to the professional and patients are being a 'pain' and creating more work. Professionals need to remember how they would wish themselves or their family members to be treated if they were a patient and treat service users accordingly.

22.6. It is important to make sure that the wishes and needs of the service user are met. Sometimes we are too wrapped up in doing other jobs that do not spend enough time with the patients as we should. However we should try and get to know our patients and make sure that their needs are met the way they want it done.

22.7. I always try to make it clear to patients that even though i may be busy that they can grab me to ask for anything at any time, many people just do "what needs to be done" and the whole process becomes very task based rather than person centred care.

23. IPW gone wrong

23.1. Victoria Climbe- No one listened to her. They talked around her and only to her auntie, who was the one who was abusing her. She came across so many services and they didnt speak to each other.

23.1.1. COMMUNICATION! - this is paramount for effective interprofessional working, if professionals are not on common ground or communicate poorly IPW goes wrong. For good patient experience it's essential that professionals communicate well but also patients and communicated to - so that they feel a part of their care, they know what is happening and they know who is involved in their care.

23.1.2. The case of Victoria Climbie prompted much change and policy making. It is a sad and distressing example of inter professional working going wrong. Communication is paramount, both between professions and agencies but also with the patients at the centre of the care. I see family members being used as interpreters all to often, this questions whether we have learnt anything at all?

23.2. I feel that IPW can be very positive and successful. However when it goes wrong and isn't as effective as what it could be, it affects the patients and I agree with the comment above that patient's end up suffering. When patients where in hospital having rehabilitation, it was many different professionals that had an input on the patients cares in order for them to become discharged. I feel as though communication is key. Verbally and also in writing. I have often seen OT's and physio's waiting around to speak to nurses because nurses are busy doing other things. I appreciate that this can't be helped at times, but maybe there could be another suitable way to communicate quick and effectively rather than just in MDT meetings and when notes get read.

23.3. It isn't only the patients who are affected when IPW goes wrong, in my experience friends and family are also greatly affected, in one particular case i came across on placement Poor communication between professionals delayed a patients discharge several times, This greatly affected the patients family particularly the patients mum and younger sibling who each time the discharge was cancelled were greatly upset. Plans were also disrupted causing frustration and anger.

23.4. Cases such as Victoria Climbie and Baby P are instances in which IPW has not necessarily performed as it should have. They are individuals who appear to have 'slipped through the net', and as such this has had a very negative impact on trust in the NHS on an epic scale.

24. Consumerism approach

24.1. Ive found that a lot of emphasis is put on patient feedback as wards are put under alot of pressure to receive 100% annually. Therefore, I've found that this style of feedback is only recommended to patients who they know will give a positive comment. As a result, this does not allow for changes to made in areas that may need to be developed that are effected patient care.

25. Democratic Approach

25.1. Does everyone want to be involved in their care?

25.1.1. i think the simple idea of ensuring that patients understand their condition, why they are having certain treatments and the possible outcomes can be enough involvement for most patients as any more information can be confusing and cause greater concern and worry. I have found that whilst working with the elderly this is definitely the case. However, having an open relationship with all services allows them to access more information if needed.

25.1.2. When there are so many options

25.2. This is an interesting one and the approach needs to be individualised, there are also capacity issues which may influence this. If the patient/service user does not wish to be or have the capacity to be their carers could be and it needs open discussion to enable them to have the choice around level of involvement.

25.3. i agree with this, i think that if a patient does lack capacity, then their family or carers should be the next communication point in order to give effective care. i think that this should all be outlined in a clear care plan which can be agreed upon to be in the patients best wishes.

25.4. "Nothing about me without me" and #HelloMyNameIs campaigns have been key in personalising care within the NHS. Maintenance of the "patient/nurse role" is something which could be considered an easy choice. The maintenance of a hierarchy of sorts is how an individual can end up invalidating their own experiences and therefore remaining within the 'institutionalised' mindset. The Four Principles of Medical Ethics (Autonomy, Beneficence, Nonmaleficence and Justice) are heavily involved within the clients informed decision making process; and we as healthcare professionals are there to facilitate and ensure these ethics are upheld.

25.5. I think that if a patient lacks capacity then the family should be included in the decisions as part of a MDT team to make sure they are acting in the best interests of the patient.

26. When a patient lacks capacity, it becomes tricky, I find. Because how can we be so sure that our patients would want people knowing about their health? That is something that is not really considered and I think perhaps it should be.

27. From experience, I find that a lot of elderly patients say things such as "whatever you want, whatever you say because your the nurse, you know best" when you ask them something about their health. When this occurs, I always try to encourage the patient to have as much input as possible in there own care and health.

27.1. I couldn't agree more. This is such a regular occurrence for me when I am on placement. The elderly patients have no self confidence and believe you know what is best for them. Even though what they say is true, no one knows them better than they know themselves. They know what they are feeling, they know what they are capable of, they know what they want and do not want. We can not decide this for them. They are their own person.